1. How sweet is sweet enough for the heart? Ronan Canavan Consultant Diabetologist St Vincent's University Hospital & St Columcilles Hospital

2. Disclosures No interests to declare & No conflict of interests to declare

3. Lugduname: between 220,000 and 300,000 times as sweet as sucrose

4. Outline Diabetes and the heart Glycaemic targets and the heart Glucose lowering treatments and the heart

5. Summary QHow important is the relationship between diabetes and the heart? AVery QWhat HbA1c target should be aimed for in a patient with heart disease? AIt depends but 6.5% (47mM/M) if you can get there relatively easily QWhat is the best way of getting to 6.5% (47mM/M)? ALifestyle, lifestyle, lifestyle and metformin

9. I beat anorexia

10. An epidemic for the 21st century 23.0 36.2 57% 23.0 36.2 57% 14.2 26.2 85% 14.2 26.2 85% 48.4 58.6 21% 48.4 58.6 21% 43.0 75.8 76% 43.0 75.8 76% 7.1 15.0 111% 7.1 15.0 111% Ireland 2007 - 2015 40% increase 39.3 81.6 108% 39.3 81.6 108% 19.2 39.4 105% 19.2 39.4 105% Ref: Diabetes Atlas second edition, IDF 2003 Global projection for the diabetes epidemic: 2003-2025 (millions)

11. Mechanisms by which glucose to damages the heart Accelerated coronary atherosclerosis Abnormalities favouring coronary thrombosis – Platelet function – Coagulation – Fibrinolysis – Endothelial function Autonomic neuropathy Left ventricular dysfunction

14. complications of Type 2 diabetes develop over decades Recruitment 1977-1991 End of study Sept. 1997 Clinical Centres23 Type 2 diabetic patients5102 Person years follow-up53,000 Funding£23 million UKPDS

15. UK prospective diabetes study (UKPDS)

16. Accord trial

19. Advance trial

21. a 17% reduction in events of non-fatal myocardial infarction (odds ratio 0·83, 95% CI 0·75–0·93), and a 15% reduction in events of coronary heart disease (0·85,0·77–0·93). intensive glucose control reduced the risk for cardiovascular disease (relative risk [RR], 0.90 [95% CI, 0.83 to 0.98]; Diabetologia. 2009 Nov;52(11):2288-98. Epub 2009 Aug 5. Intensive glucose control and macrovascular outcomes in type 2 diabetes. Turnbull FMTurnbull FM, Abraira C, Anderson RJ, Byington RP, Chalmers JP, Duckworth WC, Evans GW, Gerstein HC, Holman RR, Moritz TE, Neal BC, Ninomiya T, Patel AA, Paul SK, Travert F, Woodward M.Abraira CAnderson RJByington RPChalmers JP Duckworth WCEvans GWGerstein HCHolman RRMoritz TE Neal BCNinomiya TPatel AAPaul SKTravert FWoodward M The George Institute for International Health, University of Sydney, Sydney, NSW 2050, Australia. fturnbull@george.org.au

22. Allocation to more-intensive, compared with less-intensive, glucose control reduced the risk of major cardiovascular events by 9% (HR 0.91, 95% CI 0.84-0.99), primarily because of a 15% reduced risk of myocardial infarction (HR 0.85, 95% CI 0.76-0.94). Mortality was not decreased.

25. Lifestyle

28. Conclusions QHow important is the relationship between diabetes and the heart? AVery QWhat HbA1c target should be aimed for in a patient with heart disease? AIt depends but 6.5% (47mM/M) if you can get there relatively easily QWhat is the best way of getting to 6.5% (47mM/M)? ALifestyle, lifestyle, lifestyle and metformin